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CASE STUDIES FOR PART VIII • • • appears dazed buy nicotinell 52.5mg on-line quit smoking lungs heal, and his answers to questions are coherent CASE STUDY FOR CHAPTER 29 but slow discount nicotinell 52.5 mg on line quit smoking encouraging words. Blood sam- Heat Exhaustion with Dehydration ples are drawn, and an intravenous drip is started. The lab- oratory report shows serum [Na ] of 156 mmol/L (normal A Michigan National Guard infantry unit was sent at the end of May to Louisiana for a field training exercise. Two liters of normal saline in Michigan was cool, but during the exercise in Louisiana, (0. Well before the the temperature reached at least 30 C (86 F) every after- end of the infusion, the patient is alert, his nausea disap- noon. At 3:30 PM on the second day of the exercise, a 70-kg pears, and he asks for, and is given, water to drink. After infantryman became unsteady and, after a few more steps, the end of the infusion he is sent back to his unit with in- sat on the ground. He told his comrades that he was dizzy structions to consume salt with dinner, drink at least three and had a headache. When they urged him to drink from quarts of fluid before going to bed, and to return for fol- his canteen, he took a few swallows and said that he was low-up in the morning. What is the likely basis of the patient’s nausea, which also his rectal temperature is 38. If we assume that the patient’s total body water was 36 L CASE STUDY FOR CHAPTER 30 when he came for treatment, it can be shown that giving the patient 3 L of water without salt (by mouth and/or as an in- A Patient With Dyspnea During Exercise travenous infusion of glucose in water) would reduce serum A 56-year-old man complained of shortness of breath and [Na ] to 144 mmol/L. Such treatment would improve the pa- chest pain when climbing stairs or mowing the lawn. How might the medical offi- subjected to a stress test, with noninvasive monitoring of cer argue the case for giving 2 L of normal saline? What other (and relatively unusual) condition could produce and cardiac electrical activity. Did the medical officer rule this beats/min; blood pressure, 118/75 mm Hg; arterial blood possibility out by appropriate means? The patient’s nausea is probably a result of constriction of terminated because of the subject’s severe dyspnea. His the splanchnic vascular beds, which is part of the homeo- heart rate is 119 beats/min (his age and sex-adjusted pre- static cardiovascular response that helps maintain cardiac dicted maximal heart rate is 168 beats/min), blood pressure output and blood pressure when central blood volume is re- is 146/76 mm Hg, arterial blood oxygen saturation is 88%, duced. Central blood volume, in turn, was reduced by the and the ECG is normal (Fig. What are three lines of evidence for ventilatory limitation to constriction of the renal vascular beds, which, in turn, con- this subject’s exercise? Why did arterial blood oxygen saturation fall during exer- tion of the renin-angiotensin system) to scanty urine pro- cise? Why would endurance exercise training likely increase this large amounts of sweat, and losing correspondingly large individual’s exercise capacity? Ventilatory limitation is evidenced by severe dyspnea as a next morning without correcting the salt deficit, he is likely primary symptom in exercise, falling arterial blood oxy- to have further difficulties in the heat. Even if the medical genation, and exercise termination at relatively low heart officer has guessed incorrectly about the patient’s salt bal- rate. Arterial blood oxygen saturation fell during exercise be- fluid intake should be able to excrete any excess salt result- cause increased cardiac output (increased pulmonary blood ing from the treatment. Hyponatremia can produce symptoms similar to the pa- tent (a result of increased skeletal muscle oxygen extrac- tient’s symptoms. However, the medical officer was able to tion) increase demands for oxygenation in lungs with inade- exclude hyponatremia (although not necessarily some de- quate diffusing capacity. Exhaustion occurred before a maximal heart rate was Giving a hyponatremic patient large volumes of fluid with- reached because lung disease creates severe dyspnea even out an equivalent of salt (which would have been a reason- in mild exercise. The pulse pressure rose during exercise because sympa- thetic stimulation and enhanced venous return increase the would worsen the hyponatremia, perhaps to a dangerous stroke volume at constant arterial compliance. Endurance exercise training would have little effect on any Reference aspect of lung function. Clinical complications of body fluid and elec- adaptations within exercising muscle that would increase trolyte balance. Body Fluid Bal- muscle oxidative capacity and reduce lactic acid production. Boca Raton, FL: CRC Press, By reducing the ventilatory demands of exercise, these 1996;297–317.

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Estrogen therapy is contraindicated in cases of existing reproductive tract carcinomas or hyper- tension and other cardiovascular disease cheap nicotinell 35 mg with amex quit smoking symptoms. The prevailing MENOPAUSE opinion is that the benefit of treating postmenopausal Menopause is the time after which the final menses occurs cheap 35 mg nicotinell visa quit smoking gift ideas. Generally, menstrual cycles and bleed- ing become irregular, and the cycles become shorter from the lack of follicular development (shortened follicular INFERTILITY phases). The ovaries atrophy and are characterized by the presence of few, if any, healthy follicles. One of five women in the United States will be affected by The decline in ovarian function is associated with a de- infertility. A thorough understanding of female endocrinol- crease in estrogen secretion and a concomitant increase in ogy, anatomy, and physiology are critical to gaining in- LH and FSH, which is characteristic of menopausal women sights into solving this major health problem. Environmental factors, disor- LH stimulates ovarian stroma cells to continue producing ders of the central nervous system, hypothalamic disease, androstenedione. Estrone, derived almost entirely from the pituitary disorders, and ovarian abnormalities can interfere peripheral conversion of adrenal and ovarian androstene- with follicular development and/or ovulation. Be- ovulation occurs, structural, pathological, and/or endocrine cause the ratio of estrogens to androgens decreases, some problems associated with the oviduct and/or uterus can pre- women exhibit hirsutism, which results from androgen ex- vent fertilization, impede the transport or implantation of cess. The lack of estrogen causes atrophic changes in the the embryo, and, ultimately, interfere with the establish- breasts and reproductive tract, accompanied by vaginal ment or maintenance of pregnancy. Similar changes in the urinary tract may give rise to urinary distur- Amenorrhea Is Caused by Endocrine Disruption bances. Menstrual cycle disorders can be divided into two cate- Hot flashes, as a result of the loss of vasomotor tone, os- gories: amenorrhea, the absence of menstruation, and teoporosis, and an increased risk of cardiovascular disease are oligomenorrhea, infrequent or irregular menstruation. Hot flashes are associated with episodic in- mary amenorrhea is a condition in which menstruation has creases in upper body and skin temperature, peripheral va- never occurred. They occur concurrently with LH called gonadal dysgenesis, a congenital abnormality caused pulses but are not caused by the gonadotropins because they by a nondisjunction of one of the X chromosomes, resulting are evident in hypophysectomized women. Because the two X chro- sisting of episodes of sudden warmth and sweating, reflect mosomes are necessary for normal ovarian development, temporary disturbances in the hypothalamic thermoregula- women with this condition have rudimentary gonads and do tory centers, which are somehow linked to the GnRH pulse not have a normal puberty. Estrogen an- Other abnormalities include short stature, a webbed neck, a tagonizes the effects of PTH on bone but enhances its ef- coarctation of the aorta, and renal disorders. Another congenital form of primary amenorrhea is hy- Estrogen also promotes the intestinal absorption of calcium pogonadotropism with anosmia, similar to Kallmann’s syn- TABLE 38. Patients do not progress ies reveal that exogenous TRH increases the secretion of through normal puberty and have low and nonpulsatile LH PRL. However, they can have normal stature, press ovulation is not entirely clear. The disorder is caused by a that PRL may inhibit GnRH release, reduce LH secretion in failure of olfactory lobe development and GnRH defi- response to GnRH stimulation, and act directly at the level ciency. Primary amenorrhea can also be caused by a con- of the ovary by inhibiting the action of LH and FSH on fol- genital malformation of reproductive tract structures origi- licle development. Secondary amenorrhea is the cessation of menstrua- Anorexia nervosa, a severe behavioral disorder associated tion for longer than 6 months. Pregnancy, lactation, and with the lack of food intake, is characterized by extreme menopause are common physiological causes of second- malnutrition and endocrine changes secondary to psycho- ary amenorrhea. Other causes are premature ovarian fail- logical and nutritional disturbances. About 30% of patients ure, polycystic ovarian syndrome, hyperprolactinemia, develop amenorrhea that is not alleviated by weight gain. Strenuous exercise, especially by competitive athletes and Premature ovarian failure is characterized by amenor- dancers, frequently causes menstrual irregularities. Two rhea, low estrogen levels, and high gonadotropin (LH and main factors are thought to be responsible: a low level of FSH) levels before age 40. The symptoms are similar to body fat, and the effect of stress itself through endorphins those of menopause, including hot flashes and an in- that are known to inhibit the secretion of LH. The etiology is variable, in- of stress, such as relocation, college examinations, general cluding chromosomal abnormalities; lesions resulting illness, and job-related pressures, have been known to in- from irradiation, chemotherapy, or viral infections; and duce some forms of oligomenorrhea. Polycystic ovarian syndrome, also called Stein-Leven- Female Infertility Is Caused by thal syndrome, is a heterogeneous group of disorders char- Endocrine Malfunction and Abnormalities acterized by amenorrhea or anovulatory bleeding, an ele- vated LH/FSH ratio, high androgen levels, hirsutism, and in the Reproductive Tract obesity. Although the etiology is unknown, the syndrome The diagnosis and treatment of amenorrhea present a chal- may be initiated by excessive adrenal androgen production, lenging problem. The amenorrhea must first be classified as during puberty or following stress, that deranges the hypo- primary or secondary, and menopause, pregnancy, and lac- thalamic-pituitary axis secretion of LH.

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In early life generic nicotinell 35 mg with amex quit smoking 1 year ago, children experience are purchase 17.5mg nicotinell with mastercard quit smoking calculator, for the most part, largely develop a sense of trust in others, a sense those expressed within the family. As they of autonomy, and an awareness and mas- enter school, however, they are exposed to tery of their environment. Not only do years, they begin to learn communication they learn social relationships and coop- and social skills that enable them to inter- erative interactions, but they also begin to act effectively with others. As new skills begin to Important to their development is a bal- develop, school-age children gain the ance between encouraging initiative and capacity for sustained effort that eventu- setting limits consistently. Approval and the attainment of normal developmental encouragement by others and acceptance goals. Repeated or prolonged hospitaliza- by peers help them build self-confidence, tions may deprive children of nurturing further enhancing development. The When children with chronic illness or physical limitations of the condition or disability enter school, they may not need treatment may prevent normal activities, specific special education placement, but socialization, and exploration of the envi- they may require coordinated school in- ronment. In some cases, overly protective terventions to maximize attendance and family members may restrict activities or facilitate educational and social growth. In other instances, overly in these children’s psychological well- 10 CHAPTER 1 PSYCHOSOCIAL AND FUNCTIONAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY being, their interaction with other chil- in physical appearance caused by a chron- dren, or their academic performance. School attendance may be disrupted may also be at risk for secondary disabil- by the need for repeated absences, result- ities associated with psychosocial factors ing in the inability to interact on a con- (Anderson & Klarke, 1982; Stevens, Steele, sistent basis within the peer group, which Jutai, Kalnins, Bortolussi, & Biggar, 1996). An illness or disability during adolescence In an attempt to shield the child from can disrupt relationships with peers, hurt and emotional pain, family members resulting in delayed social and emotional may further isolate the child from social development. Limitations imposed by the interactions, creating the potential for condition, its treatment, or the sympathe- reduced self-confidence. The reluctance of tic and protective reactions by family sympathetic family members to allow the members may become barriers to the child to participate in activities in which attainment of independence and individ- there may be failure can interfere with the ual identity. Parents may be overprotective child’s ability to accurately evaluate his or to the point of infantilizing the adoles- her potential. Encouragement of social cent, thus decreasing self-esteem and self- interactions and activities to the degree confidence. If adolescents deny the limitations associated with their Perceptions of and interactions with disability or ignore treatment recommenda- peers become increasingly important as tions, there can be further detrimental ef- adolescents further define their identity fects on physical and functional capacity. With the need to establish independence, Chronic Illness or Disability in Young adolescents begin to emancipate them- Adulthood selves from their parents and may rebel against authority in general. Physical In young adulthood, individuals estab- maturation brings about a strong preoccu- lish themselves as productive members of pation with the body and appearance. Awareness tionships, and accepting social responsi- of and experimentation with sexual feel- bility. When a chronic illness or disability ings present a new dimension with which develops, its associated limitations, rather the adolescent must learn to cope. Dating than the individual’s interests or abilities, and expression of sexuality are important may define his or her social, vocational, aspects of maturation. Chronic Illness and Disability Through the Life Cycle 11 Physical limitations may also inhibit being of individuals and their families, as individuals’ efforts to build intimate rela- well as on their identity, self-concept, and tionships or to maintain the relationships self-esteem. At this established roles and associated responsi- developmental stage, established relation- bilities within the family. At the same ships are likely to be recent, and the lev- time, individuals’ partners, even when the el of commitment and willingness to make relationship is long term, may be reeval- necessary sacrifices may vary. They may per- on the nature of the condition, procre- ceive chronic illness or disability as a ation may be difficult or impossible, or, if violation of their own well-being, and the individual already has young children, they may choose to leave the relationship. In some cases the family’s Ideally, older adults have adapted to the overprotectiveness may prevent them triumphs and disappointments of life and from having experiences appropriate to have accepted their own life and immi- their own age group. Although physical limitations associated with normal aging are variable, Chronic Illness or Disability in older adults often experience diminished Middle Age physical strength and stamina, as well as losses of visual and hearing acuity. Illness Individuals in middle age are generally or disability during older adulthood can established in their career, have a commit- pose physical or cognitive limitations in ted relationship, and are often providing addition to those due to aging. The spouse guidance to their own children as they or significant others of the same age group leave the family to establish their own may also have decreased physical stami- careers and families. At the same time, na, making physical care of individuals middle-aged individuals may be assuming with chronic illness or disability more dif- greater responsibility for their own elder- ficult. When older adults with chronic ill- ly parents, who may be becoming increas- ness or disability are unable to attend to ingly fragile and dependent. During their own needs or when care in the home middle age, individuals may begin to is unmanageable, they may find it neces- reassess their goals and relationships as sary to surrender their own lifestyle and they begin to recognize their own mortal- move to another environment for care and ity and limited remaining time.

To amplify the absorptive surface further buy generic nicotinell 35 mg quit smoking with hypnosis, each ep- ithelial cell nicotinell 17.5 mg sale quit smoking free patches, or enterocyte, is covered by numerous closely packed microvilli. The various nutrients, vitamins, bile salts, and water are absorbed by the GI tract by passive, facilitated, or ac- tive transport. Malabsorption of nutrients is usually not detected unless a large portion of the small intestine has been lost or dam- aged because of disease (see Clinical Focus Box 27. Most nutrients and vitamins are absorbed by the duode- num and jejunum, but because bile salts are involved in the intestinal absorption of lipids, it is important that they not be absorbed prematurely. For effective fat absorption, the Surface area amplification by the special- small intestine has adapted to absorb the bile salts in the FIGURE 27. This idea is thy, is a common disease involving a primary lesion of the probably incorrect, however, because the intestinal brush intestinal mucosa. It is caused by the sensitivity of the border peptidases revert to normal after the healing of small intestine to gluten. Another hypothesis is that im- malabsorption of all nutrients as a result the shortening or mune mechanisms are involved. This is supported by the a total loss of intestinal villi, which reduces the mucosal fact that the number and activity of plasma cells and lym- enzymes for nutrient digestion and the mucosal surface for phocytes increase during the active phase of celiac sprue absorption. Celiac sprue occurs in about 1 to 6 of 10,000 in- and that antigluten antibodies are usually present. The highest incidence is in been demonstrated that the small intestine makes a lym- western Ireland, where the prevalence is as high as 3 of phokine-like substance, which inhibits the infiltration of 1,000 individuals. Although the disease may occur at any leukocytes into the lamina propria of the intestinal mucosa age, it is more common during the first few years and the when exposed to gluten. Occasionally, intestinal intestinal mucosa and causes the characteristic lesion. Pre- absorptive function and intestinal mucosal morphology of cisely how the binding of gluten to the intestinal mucosa patients with celiac sprue are improved with glucocorti- causes mucosal injury is unclear. Presumably, such treatment is beneficial be- patients prone to celiac sprue may have a brush border cause of the immunosuppressive and anti-inflammatory peptidase deficiency and that the consequent incomplete actions of these hormones. These are extremely ef- ficient processes, in that essentially all of the carbohy- drates consumed are absorbed. Carbohydrates are an ex- tremely important component of food intake, since they constitute about 45 to 50% of the typical Western diet and provide the greatest and least expensive source of en- ergy. The Diet Contains Both Digestible and Nondigestible Carbohydrates Humans can digest most carbohydrates; those we cannot di- gest constitute the dietary fiber that forms roughage. The monosaccharides are mainly hexoses (six-carbon sugars), and glucose is by far the most abundant of these. Glucose is obtained directly from the diet or from the digestion of dis- Carbohydrates Are Digested in Different Parts of accharides, oligosaccharides, or polysaccharides. The next the GI Tract most common monosaccharides are galactose, fructose, and The digestion of carbohydrates starts when food is mixed sorbitol. Galactose is present in the diet only as milk lactose, with saliva during chewing. The enzyme salivary amylase a disaccharide composed of galactose and glucose. Fructose acts on the -1,4-glycosidic linkage of amylose and amy- is present in abundance in fruit and honey and is usually lopectin of polysaccharides to release the disaccharide present as disaccharides or polysaccharides. Sorbitol is de- maltose and oligosaccharides maltotriose and -limit dex- rived from glucose and is almost as sweet as glucose, but sor- trins (Fig. Because salivary amylase works best at bitol is absorbed much more slowly and, thus, maintains a neutral pH, its digestive action terminates rapidly after the high blood sugar level for a longer period when similar amounts are ingested. It has been used as a weight-reduction bolus mixes with acid in the stomach. Sucrose, present in sugar cane and honey, is composed of glucose and fructose.

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